| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,451 |
825 |
$561.25 |
| D1120 |
Prophylaxis - child |
1,861 |
1,861 |
$475.25 |
| D1206 |
Topical application of fluoride varnish |
768 |
767 |
$360.00 |
| D0120 |
Periodic oral evaluation - established patient |
2,748 |
2,748 |
$337.75 |
| D0272 |
Bitewings - two radiographic images |
1,022 |
1,022 |
$131.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
502 |
410 |
$100.75 |
| D0220 |
Intraoral - periapical first radiographic image |
600 |
599 |
$95.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
886 |
885 |
$26.35 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,918 |
1,909 |
$5.70 |
| D1110 |
Prophylaxis - adult |
545 |
545 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
1,249 |
1,249 |
$0.00 |
| D0330 |
Panoramic radiographic image |
307 |
307 |
$0.00 |
| D0270 |
|
15 |
15 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
154 |
$0.00 |
| D1330 |
|
872 |
872 |
$0.00 |
| D1310 |
|
530 |
530 |
$0.00 |
| D1351 |
Sealant - per tooth |
601 |
157 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
86 |
86 |
$0.00 |